Provider Demographics
NPI:1780117630
Name:GOTTSCHLICH, GREGORY MARK
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:MARK
Last Name:GOTTSCHLICH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1221
Mailing Address - Country:US
Mailing Address - Phone:937-395-8839
Mailing Address - Fax:937-395-8387
Practice Address - Street 1:3525 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-395-8839
Practice Address - Fax:937-395-9939
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02006208A207P00000X
390200000X
OH34.014568207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0480316Medicaid